Seeking a second medical opinion: composition, reasons and perceived outcomes in Israel.

Background: Seeking a second-opinion (SO) is a common clinical practice that can optimize treatment and reduce unnecessary procedures and risks. We aim to characterize the composition of the population of SO seekers, their reasons for seeking a SO and choosing a specific physician, and their perceived outcomes following the SO. Methods: A cross-sectional national telephone survey, using a representative sample of the general Israeli population (n = 848, response rate = 62%). SO utilization was defined as seeking an additional clinical opinion from a specialist within the same specialty, for the same medical concern. We describe the characteristics of respondents who obtained SOs, their reasons for doing so and their perceived outcomes: (1) Satisfaction with the SO; (2) Experiencing health improvement after receiving a SO; (3) A difference in the diagnosis or treatment suggested in the first opinions and the second opinions; (4) Preference of the SO over the first one. Results: Most of the respondents who sought a SO (n = 344) were above 60 years old, secular, living with a partner, perceived their income to be above average and their health status to be not so good. For the patients who utilized SOs, orthopedic surgeons were sought out more than any other medical professional.Reasons for seeking a SO included doubts about diagnosis or treatment (38%), search for a sub-specialty expert (19%) and dissatisfaction with communication (19%). SO seekers most frequently chose a specific specialist based on a recommendation from a friend or a relative (33%). About half of the SO seekers also searched for information on the internet. Most of the respondents who sought a SO mentioned that they were satisfied with it (84%), felt health improvement (77%), mentioned that there was a difference between the diagnosis or treatment between the first opinion and the SO (56%) and preferred the SO over the first one (91%). Conclusions: Clinical uncertainty or dissatisfaction with patient-physician communication were the main reasons for seeking a SO. Policy makers should be aware that many patients choose a physician for a SO based on recommendations made outside the medical system. We recommend creating mechanisms that help patients in the complicated process of seeking a SO, suggest specialists who are suitable for the specific medical problem of the patient, and provide tools to reconcile discrepant opinions

The way that you do it? An elaborate test of procedural invariance of TTO, using a choice-based design

The time tradeoff (TTO) method is often used to derive Quality-Adjusted Life Year health state valuations. An important problem with this method is that results have been found to be responsive to the procedure used to elicit preferences. In particular, fixing the duration in the health state to be valued and inferring the duration in full health that renders an individual indifferent, causes valuations to be higher than when the duration in full health is fixed and the duration in the health state to be valued is elicited. This paper presents a new test of procedural invariance for a broad range of time horizons, while using a choice-based design and adjusting for discounting. As one of the known problems with the conventional procedure is the violation of constant proportional tradeoffs (CPTO), we also investigate CPTO for the alternative TTO procedure. Our findings concerning procedural invariance are rather supportive for the TTO procedure. We find no violations of procedural invariance except for the shortest gauge duration. The results for CPTO are more troublesome: TTO scores depend on gauge duration, reinforcing the evidence reported when using the conventional procedure

On the (not so) constant proportional trade-off in TTO

Abstract. Purpose: The linear and power QALY models require that people in Time Trade-off (TTO) exercises sacrifice the same proportion of lifetime to obtain a health improvement, irrespective of the absolute amount. However, evidence on these constant proportional trade-offs (CPTOs) is mixed, indicating that these versions of the QALY model do not represent preferences. Still, it may be the case that a more general version of the QALY model represents preferences. This version has the property that people want to sacrifice the same proportion of utilities of lifetime for a health improvement, irrespective of the amount of this lifetime. Methods: We use a new method to correct TTO scores for utility of life duration and test whether decision makers trade off utility of duration and quality at the same rate irrespective of duration. Results: We find a robust violation of CPTO for both uncorrected and corrected TTO scores. Remarkably, we find higher values for longer durations, contrary to most previous studies. This represents the only study correcting for utility of life duration to find such a violation. Conclusions: It seems that the trade-off of life years is indeed not so constantly proportional and, therefore, that health state valuations depend on durations

Determining value in health technology assessment: Stay the course or tack away?

The economic evaluation of new health technologies to assess whether the value of the expected health benefits warrants the proposed additional costs has become an essential step in making novel interventions available to patients. This assessment of value is problematic because there exists no natural means to measure it. One approach is to assume that society wishes to maximize aggregate health, measured in terms of quality-adjusted life-years (QALYs). Commonly, a single 'cost-effectiveness' threshold is used to gauge whether the intervention is sufficiently efficient in doing so. This approach has come under fire for failing to account for societal values that favor treating more severe illness and ensuring equal access to resources, regardless of pre-existing conditions or capacity to benefit. Alternatives involving expansion of the measure of benefit or adjusting the threshold have been proposed and some have advocated tacking away from the cost per QALY entirely to implement therapeutic area-specific efficiency frontiers, multicriteria decision analysis or other approaches that keep the dimensions of benefit distinct and value them separately. In this paper, each of these alternative courses is considered, based on the experiences of the authors, with a view to clarifying their implications

Towards a general framework for including noise impacts in LCA

Industrial Ecolog

Reasons, perceived outcomes and characteristics of second-opinion seekers: Are there differences in private vs. public settings?

Background In most countries, patients can get a second opinion (SO) through public or private healthcare systems. There is lack of data on SO utilization in private vs. public settings. We aim to evaluate the characteristics of people seeking SOs in private vs. public settings, to evaluate their reasons for seeking a SO from a private physician and to compare the perceived outcomes of SOs given in a private system vs. a public system. Methods A cross-sectional national telephone survey, using representative sample of the general Israeli population (n = 848, response rate = 62%). SO utilization was defined as seeking an additional clinical opinion from a specialist within the same specialty, on the same medical concern. We modeled SO utilization in a public system vs. a private system by patient characteristics using a multivariate logistic regression model. Results 214 of 339 respondents who obtained a SO during the study period, did so in a private practice (63.1%). The main reason for seeking a SO from a private physician rather than a physician in the public system was the assumption that private physicians are more professional (45.7%). However, respondents who obtained a private SO were neither more satisfied from the SO (p = 0.45), nor felt improvement in their perceived clinical outcomes after the SO (p = 0.37). Low self-reported income group, immigrants (immigrated to Israel after 1989) and religious people tended to seek SOs from the public system more than others. Conclusions The main reason for seeking a SO from private physicians was the assumption that they are more professional. However, there were no differences in satisfaction from the SO nor perceived clinical improvement. As most of SOs are sought in the private system, patient misconceptions about the private market superiority may lead to ineffective resource usage and increase inequalities in access to SOs. Ways to improve public services should be considered to reduce health inequalities